Serious Mental Illness, Neighborhood Disadvantage, and Type 2 Diabetes Risk: A Systematic Review of the Literature

Aim of the Study: This review aims to systematically synthesize the body of literature examining the association between neighborhood socioeconomic disadvantage and serious mental illness (SMI)–type 2 diabetes (T2D) co-occurrence. Methods: We conducted an electronic search of four databases: PubMed, Scopus, Medline, and Web of Science. Studies were considered eligible if they were published in English, peer reviewed, quantitative, and focused on the association between neighborhood disadvantage and SMI-T2D comorbidity. Study conduct and reporting complied with PRISMA guidelines, and the protocol is made available at PROSPERO (CRD42017083483). Results: The one eligible study identified reported a higher burden of T2D in persons with SMI but provided only a tentative support for the association between neighborhood disadvantage and SMI-T2D co-occurrence. Conclusion: Research into neighborhood effects on SMI-T2D comorbidity is still in its infancy and the available evidence inconclusive. This points to an urgent need for attention to the knowledge gap in this important area of public health. Further research is needed to understand the health resource implications of the association between neighborhood deprivation and SMI-T2D comorbidity and the casual pathways linking them.

Examining the Association between Neighbourhood Socioeconomic Disadvantage and Type 2 Diabetes Comorbidity in Serious Mental Illness

This study examined the association between neighbourhood socioeconomic disadvantage and serious mental illness (SMI)-type 2 diabetes (T2D) comorbidity in an Australian population using routinely collected clinical data. We hypothesised that neighbourhood socioeconomic disadvantage is positively associated with T2D comorbidity in SMI. The analysis considered 3816 individuals with an SMI living in the Illawarra and Shoalhaven regions of NSW, Australia, between 2010 and 2017. Multilevel logistic regression models accounting for suburb (neighbourhood) level clustering were used to assess the association between neighbourhood disadvantage and SMI -T2D comorbidity. Models were adjusted for age, sex, and country of birth. Compared with the most advantaged neighbourhoods, residents in the most disadvantaged neighbourhoods had 3.2 times greater odds of having SMI-T2D comorbidity even after controlling for confounding factors (OR 3.20, 95% CI 1.42-7.20). The analysis also revealed significant geographic variation in the distribution of SMI -T2D comorbidity in our sample (Median Odds Ratio = 1.35) Neighbourhood socioeconomic disadvantage accounted for approximately 17.3% of this geographic variation. These findings indicate a potentially important role for geographically targeted initiatives designed to enhance prevention and management of SMI-T2D comorbidity in disadvantaged communities.

Early Australian experience in the maintenance of schizophrenia management with 3-monthly paliperidone palmitate

OBJECTIVES:

Real-world experience from a 6-month product familiarization programme (PFP) for 3-monthly paliperidone palmitate in schizophrenia maintenance treatment.

METHODS:

Prescribers completed an online questionnaire for each patient at enrolment with further questions at second dose (re-supply) stage and a second survey of their overall experience at the end.

RESULTS:

Ninety-four patients were enrolled and received a first dose and 23 received a second dose within the 6-month programme; 51.1% had been hospitalised for symptom relapse in the previous 2 years. Reasons for prescribing were convenience of 3-monthly dosing for patients (94.7%) and patient choice (54.6%). Prescribers followed-up at least once-monthly (69.6% cases) and indicated in 48.9% they would consider shared GP care. All patients were satisfied with symptom control and either maintained functioning or showed improvement. Clinicians felt confident with administration and identifying suitable patients and were all 'satisfied' or 'somewhat satisfied' with efficacy and tolerability. All felt patients' treatment goals were either 'met' (81.3%) or 'partly met' (18.7%) and none reported dissatisfaction with relapse prevention.

CONCLUSIONS:

Convenient 3-monthly dosing was preferred by clinicians and patients, and symptoms were adequately managed. This has the potential to improve adherence and lead to better outcomes as patients only need four intramuscular doses per year.

Liraglutide prevents metabolic side-effects and improves recognition and working memory during antipsychotic treatment in rats

BACKGROUND

Antipsychotic drugs (APDs), olanzapine and clozapine, do not effectively address the cognitive symptoms of schizophrenia and can cause serious metabolic side-effects. Liraglutide is a synthetic glucagon-like peptide-1 (GLP-1) receptor agonist with anti-obesity and neuroprotective properties. The aim of this study was to examine whether liraglutide prevents weight gain/hyperglycaemia side-effects and cognitive deficits when co-administered from the commencement of olanzapine and clozapine treatment.

METHODS

Rats were administered olanzapine (2 mg/kg, three times daily (t.i.d.)), clozapine (12 mg/kg, t.i.d.), liraglutide (0.2 mg/kg, twice daily (b.i.d.)), olanzapine + liraglutide co-treatment, clozapine + liraglutide co-treatment or vehicle (Control) ( n = 12/group, 6 weeks). Recognition and working memory were examined using Novel Object Recognition (NOR) and T-Maze tests. Body weight, food intake, adiposity, locomotor activity and glucose tolerance were examined.

RESULTS

Liraglutide co-treatment prevented olanzapine- and clozapine-induced reductions in the NOR test discrimination ratio ( p < 0.001). Olanzapine, but not clozapine, reduced correct entries in the T-Maze test ( p < 0.05 versus Control) while liraglutide prevented this deficit. Liraglutide reduced olanzapine-induced weight gain and adiposity. Olanzapine significantly decreased voluntary locomotor activity and liraglutide co-treatment partially reversed this effect. Liraglutide improved clozapine-induced glucose intolerance.

CONCLUSION

Liraglutide co-treatment improved aspects of cognition, prevented obesity side-effects of olanzapine, and the hyperglycaemia caused by clozapine, when administered from the start of APD treatment. The results demonstrate a potential treatment for individuals at a high risk of experiencing adverse effects of APDs.

Therapeutic Effects of Prolonged Cannabidiol Treatment on Psychological Symptoms and Cognitive Function in Regular Cannabis Users: A Pragmatic Open-Label Clinical Trial

Introduction: Chronic cannabis use has been associated with impaired cognition and elevated psychological symptoms, particularly psychotic-like experiences. While Δ⁹-tetrahydrocannabinol (THC) is thought to be primarily responsible for these deleterious effects, cannabidiol (CBD) is purported to have antipsychotic properties and to ameliorate cognitive, symptomatic, and brain harms in cannabis users. However, this has never been tested in a prolonged administration trial in otherwise healthy cannabis users. Here, we report the first study of prolonged CBD administration to a community sample of regular cannabis users in a pragmatic trial investigating potential restorative effects of CBD on psychological symptoms and cognition.

Materials and Methods: Twenty frequent cannabis users (16 male, median age 25 years) underwent a 10-week open-label trial of 200 mg of daily oral CBD treatment, while continuing to use cannabis as usual. The majority of participants were daily cannabis users who had used cannabis for several years (median 5.5 years of regular use). Participants underwent psychological and cognitive assessments at baseline (BL) and post-treatment (PT) and were monitored weekly throughout the trial.

Results: CBD was well tolerated with no reported side effects; however, participants retrospectively reported reduced euphoria when smoking cannabis. No impairments to cognition were found, nor were there deleterious effects on psychological function. Importantly, participants reported significantly fewer depressive and psychotic-like symptoms at PT relative to BL, and exhibited improvements in attentional switching, verbal learning, and memory. Increased plasma CBD concentrations were associated with improvements in attentional control and beneficial changes in psychological symptoms. Greater benefits were observed in dependent than in nondependent cannabis users.

Conclusions: Prolonged CBD treatment appears to have promising therapeutic effects for improving psychological symptoms and cognition in regular cannabis users. Our findings require replication given the lack of a placebo control in this pragmatic trial, but suggest that CBD may be a useful adjunct treatment for cannabis dependence.

To screen or not to screen? Vitamin D deficiency in chronic mental illness

OBJECTIVES

The objective of the current study was to examine the pathology test utilisation of 25-hydroxyvitamin D (25(OH)D) within an Australian inpatient psychiatric setting.

METHOD

A retrospective audit of 300 random hospital files of those admitted as inpatients between Nov 2014 and Nov 2015 was undertaken. Data was quantitatively analysed and described.

RESULTS

The number of inpatients who had a vitamin D determination during their admission was 37/300 (12.33%). The mean vitamin D level of those tested was 51.63 nmol/l. Of those that were tested, 18/37 (48.6%) were mildly to moderately deficient. There was a statistically significant difference in age and length of stay between those that were and were not tested for vitamin D levels, p-value <0.001 and 0.017, respectively. In addition, a simple linear regression indicated a weak association between length of stay and vitamin D levels.

CONCLUSION

This audit highlights vitamin D screening inadequacy. More research is recommended to establish tangible benefits of supplementation, while local practice provides valuable data for education and policy purposes.

Exploration of food addiction in people living with schizophrenia

The term food addiction (FA) denotes a concept among researchers and lay consumers as a behavioural phenotype related to excessive food consumption. In this study we examined the prevalence of FA using the validated Yale Food Addiction Scale (YFAS) as well as the dimensional symptom count. In addition, we explored associations between participant characteristics and FA diagnosis. Outpatients attending a clozapine clinic and possessing a diagnosis of schizophrenia were invited to complete an anonymous survey using the YFAS. Ninety three surveys were used to calculate the diagnostic YFAS criteria for FA. The prevalence of FA found in this sample was 26.9%. Among individuals who did not meet "diagnostic" criteria FA, 77.4% endorsed 3 or more symptoms but did not report distress or impairment. The most common food addiction symptom was a persistent desire or repeated unsuccessful attempts to cut down consumption (97.9%). The significant finding in association between individual's characteristics and diagnosis of FA was employment. Several factors related to reported results are postulated and discussed. The current study has found the prevalence of FA amongst people living with schizophrenia to be higher than the general populations but not as high as populations with disordered eating.

What is in a name? Is food addiction a misnomer?

Recently interest in the phenomenon of food addiction has increased substantially since the inclusion of gambling disorder in the DSM-5. However the phenomenon of food addiction remains controversial and the designation continues to lack clear consideration. Few researchers have offered an explicit theoretical definition of the phenomenon which is fundamental; as it not only pertains to the aetiology it also directs research and management of the phenomenon. Therefore this review explores 'what is in a name'? Specifically possible aetiologies of food addiction, eating addiction and food addiction as an eating disorder are reviewed and the potential DSM-5 classification espoused. It is evident that the phenomenon requires further research and evaluation in order to delineate whether the phenomenon constitutes a disorder and if the phenomenon is found to be a valid entity the most appropriate designation. As it is too early to draw definitive conclusions regarding the concept all plausible designations and the associated aetiologies require further investigation.

Are community treatment orders counterproductive?

OBJECTIVE

This article briefly reviews the literature pertaining to community treatment orders (CTOs) specifically how and why they are utilised and how effective mandated community treatment really is. This review discusses the use of CTOs in the context of the recovery model.

CONCLUSIONS

This article highlights the shortfalls in the current CTO system while also demonstrating the increase in acute coercive care. The literature pertaining to the effectiveness of CTOs is inconsistent with more recent reviews denoting that there is now robust evidence the CTOs are not effective. Further treatment that aligns with the recovery model as oppose to mandated treatment is known to increase treatment compliance.

Clinical and Serologic Patterns in a Large Canadian Paediatric Cohort with Celiac Disease, At Presentation and Follow-Up

BACKGROUND: Celiac Disease (CD) is a chronic illness involving an autoimmune response to gluten, leading to small intestinal inflammation in genetically susceptible individuals. A weakness in the North American pediatric CD literature exists around serologic outcomes after initiation of a gluten free diet (GFD). Only one published North American pediatric study looks at normalization of TTG after initiation of a GFD and only assessed TTG normalization at 6 months post diagnosis. Data is also limited on other clinical patters such as levels of anemia and BMI over the course of treatment of CD.

OBJECTIVES: We sought to characterize serologic and clinical patterns in CD over an extended course using one of the largest databases of pediatric CD in North America.

DESIGN/METHODS: A retrospective review of all patients diagnosed with CD at our institution from 1996-2014 was completed. Patients required biopsy-proven CD according to the Marsh criteria. Data abstracted included age at diagnosis, gender, reason for referral, comorbidities, family history of CD and autoimmune conditions, BMI, hemoglobin, MVC, fer-ritin, IgA and anti-TTG levels. A Cochran-Armitage trend test was used to trend anti-TTG and hemoglobin normalization over time

RESULTS: 227 patients were identified who met study criteria. Visits with associated anti-TTG or hemoglobin analysis were categorized by time since diagnosis. At 6-12 months, 12-17 months, 18-23 months, 24-29 months, 30-35 months and 36-41 months from diagnosis 66.7% (n=144), 75% (n=40), 85.6% (n= 76), 86.9 (n= 23), 93.5 (n=62) and 95% (n= 20) of patients had normalized their anti-TTG levels respectively from a baseline of 100% abnormal TTG and 5.7% (n=140), 7.3% (n=41), 5.1% (n=77), 5.0% (n=20), 1.6% (n=60) and 5.0% (n=20) had anemia versus 18% at presentation.

CONCLUSION: The small p-value (p=&lt;0.0001) for the Cochran-Armitage test for anti-TTG normalization indicates the increased probability of a normalized anti-TTG as time from diagnosis increases. Knowledge of the slope of this trend could assist clinicians with better understanding the effectiveness of treatment for their patients. In this cohort, anti-TTG levels normalized over a broad time span, with increasing numbers of patients normalizing their anti-TTG through to the end of the study period. Further research goals aim to determine predictors of early anti-TTG normalization. In this cohort, the proportion of patient with anemia quickly decreased from a baseline of 18%, to general pediatric population levels between 6-12 months after treatment initiation and remained stable in this range through to the end of the study period with a non-significant p value (p=0.06) for trend over time.

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Assessment of Gluten Exposures in Children with Celiac Disease

BACKGROUND: Celiac Disease (CD) is one of the most common chronic diseases of childhood. A strict, lifelong gluten-free diet (GFD) remains the sole treatment for CD. Reports of accidental or intentional ingestion of gluten are common, but little is known about the sources or context of such exposures.

OBJECTIVES: We sought to ascertain the self-reported causes for gluten exposure for children with Celiac Disease.

DESIGN/METHODS: Parents of children with biopsy-proven CD followed at McMaster Children’s Hospital were asked to review a 22-item questionnaire listing sources, situations and causes of gluten exposure for their child. The questionnaire encompassed both intentional and unintentional gluten exposures and was developed through consultation with Registered Dietitians and Faculty in the Division of Pediatric Gastroenterology at McMaster Children’s Hospital. Children independently completed a similar 21-item questionnaire adapted for pediatric use. Participants were invited to describe any additional sources or circumstances leading to gluten consumption not captured in the questionnaire.

RESULTS: A total of 123 families participated in the study with a median of 32 months on a GFD. A minimum of one cause of gluten exposure was selected by 65% of parents and 60% of children. Restaurant dining was identified as a source of gluten consumption by 39% of parents, due to a lack of knowledge of the GFD by restaurant staff or poor labeling of menu items. Other commonly selected items on the parent questionnaire included: difficulty while traveling (13%), to avoid exclusion at social events (12%), and a lack of negative symptoms following gluten exposure (9%). Few parents identified cost (2%), or the availability of gluten-free food as a concern (5%). Children most commonly identified restaurant eating (32%), and the lack of any negative symptoms from eating gluten as the main causes of gluten exposure (14%). In this study population, 11% of children acknowledged consuming gluten because they felt left out at either home, school or with friends.

CONCLUSION: This study provides information about the common causes of gluten exposure for children with CD in Ontario, Canada. Restaurant dining and travel were the most commonly identified sources of gluten ingestion. Our study highlights the need for improved menu labeling and education of restaurant staff, requiring both policy changes and dialogue with food service industries. While availability of gluten-free products has greatly improved, exclusion from social activities remain a concern for both children and their parents. Further qualitative studies may build on these identified themes to better understand challenges families face with the GFD.

Establishing a Recovery-Focused Rehabilitation Unit: A Case Example

This study highlights lessons learnt from establishing a new recovery-focused inpatient rehabilitation unit in a typical regional city of New South Wales. We have learnt that the most important aspects are recruitment, retention and training of dedicated staff and a belief that recovery is possible. Strategies employed to meet the challenges of integrating a recovery-based practice into this type of setting may be transferable to other new services or existing services of a similar nature. We have provided a summary of standard outcome measures reflecting the performance of the unit for the first 2 years of functioning.

NEGATIVE SYMPTOMS IN SCHIZOPHRENIA: THE PREVAILING CHALLENGES

Although many advances in the understanding and treatment of schizophrenia have been made many challenges still remain. Most notably is the lack of understanding pertaining to the negative symptoms dimension of schizophrenia and the treatment of such symptomology? Primary negative symptoms affect 20-40% of individuals with schizophrenia and are associated with the greatest impacts upon functional impairment and quality of life. A qualitative review of the prevailing challenges related to the nature, assessment and treatment of negative symptoms was conducted. The current literature in each of the aforementioned areas pertaining to primary negative symptoms was reviewed with a focus upon the key challenges and directions for future research. The results of the qualitative review indicate that the construct of negative symptoms requires further delineation and recent work in the area of the assessment of negative symptoms necessitates further development. In regards to the treatment of negative symptoms no definitive directions are espoused due to the extent of the dearth of knowledge in the area as highlighted in the discussion. The area of negative symptoms research requires multi-disciplinary collaborative research to address the major challenges to the understanding, assessment and treatment of negative symptoms in schizophrenia to improve the quality of life and functional outcomes of those with primary negative symptoms.

Chronic betahistine co-treatment reverses olanzapine's effects on dopamine D₂ but not 5-HT2A/2C bindings in rat brains

Olanzapine is widely prescribed for treating schizophrenia and other mental disorders, although it leads to severe body weight gain/obesity. Chronic co-treatment with betahistine has been found to significantly decrease olanzapine-induced weight gain; however, it is not clear whether this co-treatment affects the therapeutic effects of olanzapine. This study investigated the effects of chronic treatment of olanzapine and/or betahistine on the binding density of the serotonergic 5-HT2A (5-HT2AR) and 5-HT2C (5-HT2CR) receptors, 5-HT transporter (5-HTT), and dopaminergic D₂ receptors (D₂R) in the brain regions involved in antipsychotic efficacy, including the prefrontal cortex (PFC), cingulate cortex (Cg), nucleus accumbens (NAc), and caudate putamen (CPu). Rats were treated with olanzapine (1 mg/kg, t.i.d.) or vehicle for 3.5 weeks, and then olanzapine treatment was withdrawn for 19 days. From week 6, the two groups were divided into 4 groups (n=6) for 5 weeks' treatment: (1) olanzapine-only (1 mg/kg, t.i.d.), (2) betahistine-only (9.6 mg/kg, t.i.d.), (3) olanzapine and betahistine co-treatment (O+B), and (4) vehicle. Compared to the control, the olanzapine-only treatment significantly decreased the bindings of 5-HT2AR, 5-HT2CR, and 5-HTT in the PFC, Cg, and NAc. Similar changes were observed in the rats receiving the O+B co-treatment. The olanzapine-only treatment significantly increased the D₂R binding in the Cg, NAc, and CPu, while the betahistine-only treatment reduced D₂R binding. The co-treatment of betahistine reversed the D₂R bindings in the NAc and CPu that were increased by olanzapine. Therefore, chronic O+B co-treatment has similar effects on serotonin transmission as the olanzapine-only treatment, but reverses the D₂R that is up-regulated by chronic olanzapine treatment. The co-treatment maintains the therapeutic effects of olanzapine but decreases/prevents the excess weight gain.